Faculty Bibliography

Patellar position and alignment may be measured on routine axial radiographs by various techniques; however, the agreement and reliability of such measurements with a resurfaced patella remain unknown. This study evaluated the range and reliability of lateral patellar tilt and lateral patellar displacement following total knee arthroplasty (TKA) with a resurfaced patella among three observers on 45° Merchant view in 139 TKAs. Intraclass correlation coefficient (ICCs) were used to evaluate intraobserver agreement (IOA) and inter-rater reliability (IRR). IRR was high between each of the observers for lateral patellar tilt (ICC = 0.8) and lateral patellar displacement (ICC = 0.87). IOA was also high upon repeat measurement for the same observer for lateral patellar tilt (ICC ≥ 0.90) and lateral patellar displacement (ICC ≥ 0.86). Therefore, lateral patellar tilt and lateral patellar displacement are reproducible measurements of patellar position on a Merchant axial radiograph following a well-functioning TKA with a resurfaced patella.

AIMS/OBJECTIVE:The COVID-19 pandemic led to a swift adoption of telehealth in orthopaedic surgery. This study aimed to analyze the satisfaction of patients and surgeons with the rapid expansion of telehealth at this time within the division of adult reconstructive surgery at a major urban academic tertiary hospital. METHODS:A total of 334 patients underging arthroplasty of the hip or knee who completed a telemedicine visit between 30 March and 30 April 2020 were sent a 14-question survey, scored on a five-point Likert scale. Eight adult reconstructive surgeons who used telemedicine during this time were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modelling. RESULTS:A total of 68 patients (20.4%) and 100% of the surgeons completed the surveys. Patients were "Satisfied" with their telemedicine visits (4.10/5.00 (SD 0.98)) and 19 (27.9%) would prefer telemedicine to in-person visits in the absence of COVID-19. Multivariate ordinal logistic regression modelling revealed that patients were more likely to be satisfied if their surgeon effectively responded to their questions or concerns (odds ratio (OR) 3.977; 95% confidence interval (CI) 1.260 to 13.190; p = 0.019) and if their visit had a high audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219; p = 0.042). Surgeons were "Satisfied" with their telemedicine experience (3.63/5.00 (SD 0.92)) and were "Fairly Confident" (4.00/5.00 (SD 0.53)) in their diagnostic accuracy despite finding the physical examinations to be only "Slightly Effective" (1.88/5.00 (SD 0.99)). Most adult reconstructive surgeons, seven of eight (87.5%) would continue to use telemedicine in the future. CONCLUSION/CONCLUSIONS: 2021;103-B(6 Supple A):196-204.

Introduction/UNASSIGNED:Intra-articular corticosteroid (CSI) or hyaluronic acid (HAI) injections alleviate symptoms of osteoarthritis in patients who may be candidates for total hip or total knee arthroplasty (THA/TKA). However, their effect on time to total joint arthroplasty (TJA) and complications remains uncertain. We sought to evaluate (1) delay in time to surgery for patients receiving injections prior to THA/TKA (2) incidence of patients that receive injections, (3) type and number of injections, and (4) compare complication rates between patients with and without injections. Methods/UNASSIGNED:We retrospectively reviewed 3340 consecutive TJA (1770 THA and 1570 TKA). Patients were divided into two cohorts depending if they received preoperative intra-articular injection or not. We identified dates of first clinic presentation and index surgery, injection type, total administered, and 90-day complications, including periprosthetic joint infection. Results/UNASSIGNED:150/1770 THA and 192/1570 TKA patients received injections (8.5%vs.12.2%,p = 0.0004). Time from first presentation to clinic to TJA was significantly greater in patients receiving injections [12.4 ± 11 months vs.7.3 ± 10.7,p < 0.001 for THA; 20.0 ± 17.4 months vs.11.6 ± 15.4,p < 0.001 for TKA]. This delay in time was greater in TKA versus THA (8.4 months vs.5.1,p < 0.001). TKA patients had a higher incidence of receiving HAI versus THA patients (9%vs.0.6%,p < 0.0001). There were no differences in overall complication profiles (p = 0.19 for THA, p = 0.3 for TKA). Conclusion/UNASSIGNED:Injections are associated with an increased time to TJA by a statistically significant amount, however its clinical significance is debatable. Injections are safe if administered at least three months preoperatively. If patients present with appropriate surgical indications and are ready, we do not recommend intra-articular injections to delay surgery.

Background/UNASSIGNED:An adult reconstruction (AR) fellowship is designed to provide advanced training for a broad range of primary reconstructive and complex knee revision surgeries. This study aims to identify outcome differences between primary total knee arthroplasty (TKA) performed by AR fellowship-trained surgeons and non-AR (NAR) fellowship-trained surgeons. Material and Methods/UNASSIGNED:-tests. Primary outcomes were compared using multilinear regressions, controlling for demographic differences. Results/UNASSIGNED:< .001) scores were significantly higher for the AR cohort but did not exceed the minimal clinically important difference. Conclusion/UNASSIGNED:This study demonstrates significantly shorter surgical times and greater improvements in KOOS, JR and VR-12 PCS scores associated with TKAs performed by AR fellowship-trained surgeons. Level III Evidence/UNASSIGNED:Retrospective Cohort Study.

Objective: We sought to identify novel genes and to establish the contribution of known genes in a large cohort of patients with nonsyndromic sporadic polymicrogyria and epilepsy.
Method(s): We enrolled participants with polymicrogyria and their parents through the Epilepsy Phenome/Genome Project. We performed phenotyping and whole exome sequencing (WES), trio analysis, and gene-level collapsing analysis to identify de novo or inherited variants, including germline or mosaic (postzygotic) single nucleotide variants, small insertion-deletion (indel) variants, and copy number variants present in leukocyte-derived DNA.
Result(s): Across the cohort of 86 individuals with polymicrogyria and epilepsy, we identified seven with pathogenic or likely pathogenic variants in PIK3R2, including four germline and three mosaic variants. PIK3R2 was the only gene harboring more than expected de novo variants across the entire cohort, and likewise the only gene that passed the genome-wide threshold of significance in the gene-level rare variant collapsing analysis. Consistent with previous reports, the PIK3R2 phenotype consisted of bilateral polymicrogyria concentrated in the perisylvian region with macrocephaly. Beyond PIK3R2, we also identified one case each with likely causal de novo variants in CCND2 and DYNC1H1 and biallelic variants in WDR62, all genes previously associated with polymicrogyria. Candidate genetic explanations in this cohort included single nucleotide de novo variants in other epilepsy-associated and neurodevelopmental disease-associated genes (SCN2A in two individuals, GRIA3, CACNA1C) and a 597-kb deletion at 15q25, a neurodevelopmental disease susceptibility locus.
Significance: This study confirms germline and postzygotically acquired de novo variants in PIK3R2 as an important cause of bilateral perisylvian polymicrogyria, notably with macrocephaly. In total, trio-based WES identified a genetic diagnosis in 12% and a candidate diagnosis in 6% of our polymicrogyria cohort. Our results suggest possible roles for SCN2A, GRIA3, CACNA1C, and 15q25 deletion in polymicrogyria, each already associated with epilepsy or other neurodevelopmental conditions without brain malformations. The role of these genes in polymicrogyria will be further understood as more patients with polymicrogyria undergo genetic evaluation.
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BACKGROUND:Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk. METHODS:An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines. RESULTS:VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts. CONCLUSION/CONCLUSIONS:VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.

Background/UNASSIGNED:Total hip arthroplasty (THA) is an effective operation for patients with hip osteoarthritis; however, patients with hip dysplasia present a particular challenge. Our novel study examined the effect of robot-assisted THA in patients with hip dysplasia. Methods/UNASSIGNED:We retrospectively reviewed patients with developmental dysplasia of the hip undergoing primary THA using robotic arm assistance at 2 institutions from January 2010 to January 2017. Patients undergoing revision arthroplasty were excluded. Preoperatively, all patients underwent a computed tomography scan so that 3-dimensional templating could be performed. Hip range of motion (ROM) and clinical leg length discrepancy were recorded preoperatively. Two independent observers calculated Crowe and Hartofilakidis grades for each operative hip. At the final follow-up, hip ROM, postoperative complications, and modified Harris Hip scores were obtained. Results/UNASSIGNED:< .0002). There were no complications during the short-term interim follow-up (mean: 3.1 years). Conclusions/UNASSIGNED:Robot-assisted THA can be a useful method to ensure adequate component positioning and excellent outcomes in patients with hip dysplasia. Level of Evidence/UNASSIGNED:Level III, Retrospective.

Selective supplementation of acetabular component fixation with a screw during primary total hip arthroplasty (THA) assumes that the surgeon can detect when an acetabular component needs additional stability. In contrast, nonselective screw users do not alter their practice based on their interpretation of stability and either use screws all or none of the time. We aimed to determine the effect of selective screw use on aseptic acetabular component loosening. We retrospectively reviewed aseptic failures of acetabular components after primaty THA. We compared the survivorship of selective and nonselective supplementation of acetabular fixation with respect to time to revision, obesity, and screw use. Selective screw use (n = 16) was associated with earlier acetabular component aseptic loosening (median: 1.9 years; interquartile range [IQR]: 1.1-5.0) compared to nonselective screw use (n = 22; median: 5.6 years; IQR: 2.0-15.3; P = .010). Selective screw use was independently associated with earlier revision after adjusting for patient obesity. Obesity was associated with selective screw use in 50% of the cases vs 14% of nonselective cases (odds ratio: 6.3; confidence interval: 1.2-25.2; P = .028), possibly reflecting the increased difficulty in achieving acetabular component stability in this and other settings with compromised bone. Surgeons should carefully assess component stability at time of primary THA. If the acetabulum is not stable, the addition of screws alone may not be sufficient for acetabular component stability.

BACKGROUND:Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). METHODS:A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. RESULTS:A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). CONCLUSION/CONCLUSIONS:Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. LEVEL OF EVIDENCE/METHODS:III, Retrospective Observational Analysis.